Provider Demographics
NPI:1235790577
Name:LASITA, JACLYN (RN, PNP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:LASITA
Suffix:
Gender:F
Credentials:RN, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 TARPON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9579
Mailing Address - Country:US
Mailing Address - Phone:631-740-0769
Mailing Address - Fax:
Practice Address - Street 1:263 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1224
Practice Address - Country:US
Practice Address - Phone:631-419-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY745257163WH0200X, 163WP0200X
NYF383584363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics